A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?
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<p><img src="https://naxlex.com/nursing/assets/images/study_guides/Picture1AB_1746709047.jpg" class="img-fluid" /></p>
The Correct Answer is B
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.
B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.
C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.
D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.
Correct Answer is C
Explanation
A. Dry excess sanitizer from hands with a paper towel: Hand sanitizer should be allowed to dry naturally, and there is no need to wipe it off with a paper towel. Wiping off the sanitizer could reduce its effectiveness in killing germs.
B. Rubs hands together for 10 seconds after applying sanitizer: The Centers for Disease Control and Prevention (CDC) recommends rubbing hands together for at least 20 seconds to ensure that the hand sanitizer covers all surfaces of the hands and effectively kills germs.
C. Apply enough sanitizer to completely cover both hands: It is important to apply a sufficient amount of hand sanitizer (usually about a dime-sized amount) to cover both hands entirely. The sanitizer should be rubbed into all areas of the hands, including between fingers and under nails, until the hands are dry.
D. Clean sanitizer from under fingernails using an orangewood stick: This is unnecessary if the sanitizer is applied properly and rubbed in completely. Hand sanitizer should be used to cover all areas of the hands, including under fingernails, and should be allowed to dry naturally without needing to clean it with a stick.
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